Enhanced Recovery after Maxillofacial Surgery Bristol Royal

Enhanced Recovery after Maxillofacial Surgery Bristol Royal Infirmary Rory Spanton Enhanced Recovery Nurse Practitioner Bristol Royal Infirmary July 2019

Attenuate perioperative stress Maintain physiological function Minimise post-op complications Reduce length of stay Improve clinical outcomes

BRI enhanced recovery timeline 2012 – Colorectal (all), thoracic (all) and oesophagectomy 2013 – Major free-flap 2015 – Whipple’s procedure, gastrectomy (total, subtotal), ENT (over 48 hours stay), all elective inpatient max fax procedures 2016 – Open liver resection 2018 – ERAS Lead, lap liver, bypass, distal panc, emergency laparotomy pathway,

Rory Spanton - ERAS Nurse Practitioner Natasha Joshi - ERAS Clinical Lead Lesley Wood – Data collection Sandy Johnson – Data collection Ceri Hughes – Max Fax surgical Lead Pain Specialist Nurse Dietician Ward Nurse Patient and family Physio Surgeon Anaesthetist ICU

Preoperative Intraoperative Postoperative Pre op Visit Patient fit for surgery Explanation of ERP verbal and written Admitted on day of surgery Carbohydrate drinks given pre-op Avoided long acting sedative premed Appropriate antibiotics given prior to KTS Individualised goal directed fluid therapy Hypothermia Prevention Avoid post-op crystalloid overload Avoid systemic opiates post-op Early post-op nutrition Targeted individual nausea and vomiting control Mobilisation within 24 hours

Percentage Compliant Overall % Compliance with Enhanced Recovery Components Max Fax Surgery - January 2019 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% t si vi l e s y d n p g) on ur ak tro ap oa to tio in t r l si o n s a i r e h m e in c c co ve th po 4 ar d di in tiv o 2 f n r g o e w s d a n i o y n i io fo te m fo id in er el iti op flu nt ia sk ay re d lo th fit a i iv l i a op p m d p l t d l r o t o w a t ta o e e p e e as vo ct n er (in ys iv ic Pr th ex /s or d t e d r o p i r i l e a n r m c i n o a s o e d p an at on rb re ld tio ve st s a is es -ti d se i i l e a c y p e t r s n i e i t v s s a s g t e n itt go ob io er nu au ta ev of tin nd ve m d r p b M n i c n i a p e e d p t a g to c o a d is tie g ia an en os an st ks al se nt n i Pa m p p d ir tt u o l n e i r i i lo o d p w ua at dr vi he ng vo y pr of t i l i d P n i A e r p d o d e v i a at ve In Ea yp di nc vo of dr gi n H a i A y t id h in P ed m vo bo d r et A a a g r C e Ta Th y er g r su RP E of ry ge r su A N/ , N Y, ERP Components

MDT buy-in Overall component compliance 70-80% “ to improve outcomes ” Gotlib et al (2015)

100% Max Fax Surgery % Compliance with Enhanced Recovery Components Overall Feb 2017 - January 2019 90% 80% Percentage Compliant 70% 60% 50% 40% 30% 20% 10% 0% 7 7 7 7 7 8 8 8 8 8 8 8 9 6 7 7 7 7 7 7 7 8 8 8 8 8 -1 -1 n-1 b-1 -1 -1 -1 -1 n-1 b-1 -1 -1 -1 n-1 -1 n-1 -1 n-1 l-1 g-1 p-1 ct-1 l-1 g-1 p-1 ct-1 r r r r v c y v c y c u u a a p p a a J J O O Ja A Ja A Ja De Fe M Ju De Fe M Ju De Se No Se No M Au M Au Month

What data do we collect? ALL elective inpatients (over 24 hour stay) ERAS compliance Length of stay Readmissions Reoperations

Max Fax Surgery Median Length of Stay by Month (By Operation Group) Overall Feb 2017 - January 2019 80 Excision submandibular gland 70 Major - Flap/ Reconstruction Major - Free Flap 60 Maxillectomy Neck dissection Days 50 Osteotomy Other 40 Parotidectomy 30 Thyroidectomy 20 Comb maxill & neck diss'n Comb neck diss'n & parotid 10 Comb thyroid & neck diss'n 0 17 17 17 17 17 18 18 18 18 19 17 17 17 17 17 17 18 18 18 18 18 18 18 18 b- ar- pr- ay- un- ul- ug- ep- ct- ov- ec- an- eb- ar- pr- ay- un- ul- ug- ep- ct- ov- ec- ane J J O O A J A J F M J D F M J D S N S N M A M A Month

Recommendations for free flap surgery Consensus review Core principles the same across specialties

Bristol Royal Infirmary 2016

Free Flap ERAS compliance (%) 100 90 80 70 60 50 40 30 20 10 0 l s s S e y n n n d fit ry ce ur ur ap tro tiv KT oa tio tio tio ge l r o o a as n ian a r n p r o e l h h d o e u p m m ve ed th rt se fs ac ov 24 24 or su io ss d re d e f o i om r i e n d s p n n c n i u i i s y o i o u fl it ia sp llo As ith ith da Av d na kc m AS vis tic ta e w w t n r n R t i s o e e o c i y g h lE dr op ng on cr ire tib ar ed ot eb isi iti ba n T d d l r r p r tt r i i i l t a P A o a C ve Hy ob Nu dm Av d Go M A n a en ir tt W Feb 2014 - Jan 2015 Feb 2018 - Jan 2019

Prepare 4 Surgery Every Monday, 2pm - POAC

Areas for improvement 1. Pathway usage

2. POAC and ward staff engagement Percentage Com pliant Overall % Compliance with Enhanced Recovery Components Max Fax Surgery - January 2019 100% 80% 60% 40% 20% 0% ERP Components 2014 (%) 2018 (%) Pre-op visit compliance 100 100 Assessed as fit 100 100 Carb drink consumption 74 47 Written and verbal ERAS information 55 52 Target nausea control 97 95 Goal directed fluid therapy 10 52 Mobilising within 24 hours 7 38 Nutrition within 24 hours 90 86

MEDIAN LENGTH OF STAY 3. Data collection Excision submandib ular gland Major - Major Comb Comb Neck Osteoto Flap/ Maxillec Parotide Thyroid maxill neck Other ctomy ectomy neck& diss'n Reconst Free tomy dissecti my & on ruction Flap diss'n parotid Comb Overall thyroid Median & neck LOS diss'n Month Current issues Jan-17 15.5 3.0 8.0 1.0 1.0 Feb-17 19.0 1.0 4.0 1.0 1.0 11.0 1.0 5.0 1.0 1.0 1.0 6.5 1.0 1.0 1.0 8.0 1.5 1.0 3.0 1.0 1.0 9.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.5 1.0 1.0 1.0 Mar-17 Apr-17 1.0 May-17 Retrospective collection Ambiguous categories (‘other’) Is the data actually being used? 17.0 Jun-17 15.0 11.0 17.0 19.0 6.0 Jul-17 1.0 3.0 1.0 1.0 Aug-17 1.0 16.5 16.0 8.0 1.0 1.0 Sep-17 1.0 69.0 1.0 9.0 1.0 1.0 Oct-17 1.0 25.5 1.0 1.0 1.0 Nov-17 1.0 14.0 5.0 1.0 1.0 Dec-17 11.0 Jan-18 10.5 Feb-18 Mar-18 4.0 8.0 1.0 Apr-18 Jun-18 Jul-18 1.0 Aug-18 1.0 Oct-18 1.0 Nov-18 1.0 Dec-18 8.0 1.0 1.0 1.0 3.0 8.0 1.0 1.0 1.0 1.5 1.0 1.5 25.0 4.5 1.0 1.0 3.0 5.0 1.0 1.0 17.0 1.5 2.0 1.0 1.0 1.0 1.0 1.0 2.0 1.0 1.0 1.0 1.0 20.0 16.5 7.0 20.0 1.0 21.0 3.0 5.0 1.0 1.0 5.0 3.0 1.0 1.0 1.0 2.0 9.0 2.0 1.0 1.0 1.0 4.0 1.5 1.0 12.0 16.0 Sep-18 1.0 1.0 15.0 36.0 May-18 1.0 1.0 1.0 3.0 2.9 4.0 1.0 1.0 1.0 1.0 1.0 2.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.5 1.0 1.0

Questions and discussion? [email protected] Reading: 1.Gotlib Conn L, McKenzie M, Persall EA, McLeod RS. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences. Implement sci. 2015;10:99. 2.Ljungvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery; a Review. JAMA Surg. 2017;152(3):292-298. 3. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014;101:172–88. 4. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urnam RD, Chnag GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: 2018 et al colorectal guidelines. World J Surg. 2018; doi.org/10.1007/s00268-018-4844-y 5. Wynter-Blyth V, Moorthy K. Prehabilitation: Preparing patients for surgery. BMJ. 2017;358:j3702. 6. Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet 2015; 385(Suppl ):S11 7. Scheede-Bergdahl C,Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when,what, how, who and where next? Anaesthesia 2019, 74 (Suppl. 1), 20–26 8. Neville A. Leel L, Antonescu I, Mayo NE, Vassioiou MC, Fried GM, Feldman LS. Systematic review of outcomes used to evaluate enhanced recovery after surgery. BJS. 2014;101(3):159-171. 9. Laudicella, M., Walsh, B., Munasinghe, A. and Faiz, O. (2016) Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study. BMJ Open [online]. 6 (11), pp. e012977. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2016-012977doi:10.1136/bmjopen-2016-012977.